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Ailing and Failing Endosseous Dental Implants: A Literature Review

Abstract
Although the overall success rate of implant dentistry is very high, dental implants occasionally fail. It is essential for the clinician to recognize unhealthy implants and to determine whether they are ailing, failing, or failed prior to beginning any salvage efforts. Ailing and failing implants are amenable to therapy. Implants diagnosed as failed should be removed. This review provides the reader with information on non-surgical and surgical therapies available for managing ailing and failing implants. Undoubtedly, the best steps to avoid encountering ailing or failing implants involve proper case selection, excellent surgical technique, placing an adequate restoration on the implant, educating the implant patient to maintain meticulous oral hygiene, and evaluating the implant both clinically and radiographically at frequent recall visits. Keywords: Ailing implant, failing implant, failed implant, implantoplasty Citation: Ashley ET, Covington LL, Bishop BG, Breault LG. Ailing and & Failing Endosseous Dental Implants: A Literature Review. J Contemp Dent Pract 2003 May;(4)2:035-050.

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The Journal of Contemporary Dental Practice, Volume 4, No. 2, May 15, 2003

titanium implants have joined the armamentarium of the restorative dentist. This review provides the reader with information on therapies available for treating ailing and failing implants. and guided bong 2 Failure Clinically. Non-functional. ailing and failing implants may be indefinitely retained. Dental implants are becoming more predictable. Implants also do not require preparation of healthy. Therefore. In addition. Recently. in most cases.2 Other studies have reported long-term success rates for the maxilla at 92% and the mandible at 94% at 5 years3 with up to 78% success in the maxilla and 86% success in the mandible 4 at the 15-year time period. 2003 . failed implants must be removed (Figure 2) to prevent the associated bone loss from continuing. The benefits of endosseous dental implants are many. A failed implant also may exhibit a dull sound upon percussion and/or demonstrate a peri-implant radiolucency (Figure 1).10 However.Introduction Throughout the history of dentistry. Implants are now becoming mainstream treatment in dentistry. such as maxillary sinus lifts. adequate radiographic bone levels. and the ability of the patient to keep the area clean. Implants are being placed in greater numbers each year as patients become more familiar with their advantages. Studies have demonstrated success rates ranging from 80-92% success for the maxilla over 5 to 10 years. highly esthetic. It was believed an implant was successfully integrated when there was direct contact between bone and the titanium implant (at the light microscopic level) with no fibrous connective tissue interface. No. today’s dental consumer is better informed and more often requests dental implants as their treatment of choice. the criteria for success have evolved beyond the initial goal of osseointegration. Advances in surgical procedures. Volume 4.5-9 Although the success rate of implants is very high. As a result. lack of osseointegration leads to implant mobility and subsequent failure.11 Dental implants provide the patient with a fixed anchor for a tooth or teeth that need not be removed at night or for cleaning. Treatment options have evolved from acrylic dentures to metal framework removable partial dentures to fixed partial dentures. 2. Implant success in the 21st century involves other factors including: stability of the implant. lateral inferior alveolar nerve placement. asymptomatic teeth. clinicians and patients have struggled with options for replacing missing teeth. the edentulous patient is afforded a prosthesis that is both stable and. regeneration (GBR) allow the practitioner to place implants in patients that would not have received this treatment option 10 years ago.1. Success Osseointegration was the hallmark of success in implant dentistry in the 1980s. with proper diagnosis and treatment. minimal probing depths around the implant. In many cases.12 The option of removing the The Journal of Contemporary Dental Practice. May 15. lack of symptoms or evidence of infection. Once the dentist introduces implants as a treatment option. the patient may access information using resources such as the Internet to learn more about this treatment modality. implants occasionally fail. a mobile implant is a failed implant.

May 15.20 Jaffin and Berman21 report a 5 year success rate of 1. Ailing vs.32 Therefore. an implant exhibiting peri-implant mucositis is an ailing implant. Inferior surgical technique is another possible cause of implant failure. II. No. 2. leading to failure. Overall failure rates have been reported as 11.1%) and the anterior maxilla (16.26 Inadequate implant restorations also may contribute to implant failure. However.30 It is necessary to distinguish between an ailing versus a failing implant to determine the treatment steps necessary to salvage the unhealthy implant.18.30.5% over 5 years with this type of implant.82%). in contrast to Type IV bone which has a thin cortex. Implants fail for a variety of reasons. this bone loss tends to become static at 3 The Journal of Contemporary Dental Practice. Recent studies have demonstrated similar failure rates between wellcontrolled diabetics and non-diabetic controls24 or only slightly higher failure rates with Type 2 (non-insulin dependent) diabetics. However. II.25 Of course. Failure results from excessive temperature elevation in bone during placement. Implants are doomed to fail when placed in patients having insufficient quality and/or quantity of bone to support the implant fixture. Implants exhibiting soft tissue problems exclusively are classified as ailing and have a more favorable prognosis. Fugazzotto et al. Volume 4. During surgical placement. and poor medullary strength. Only 3% of fixtures placed in Types I. leading to necrosis of the supporting bone around the implant. poorly restored implants may have overhangs or be overcontoured. or implant surface treatments and characteristics. Patients that smoke cigarettes have demonstrated an increase in implant failures.”29. failure rates were higher in the posterior maxilla (19.28% for smokers compared to 4.23 Finally. Obviously. Some studies have related failures to biological or microbiological factors13-17.054 Branemark (screw type) implants placed in private practice with regards to bone quality. biomaterial factors. systemic health of the patient is important when considering implants.76% for non-smokers.23 Additionally. In some instances.27. Failing Implants Clinically unhealthy implants are classified as “ailing” or “failing. which may lead to plaque accumulation and eventual failure. 2003 . implant failure may result from inadequate irrigation of the surgical site or from using low torque and excessive drill speed during placement.31 (Figures 3 & 4) Peri-implant mucositis involves inflammatory changes confined to the soft tissue surrounding an implant. and III bone offer good strength. uncontrolled diabetic patients are poor candidates for any surgical procedure. Type I.19 Improper patient selection is a significant reason for failure. bone quality may be less of a concern when cylinder type implant fixtures are utilized. and III bone were lost compared to a 35% failure rate of implants placed in Type IV bone. low trabecular density.implant and allowing for healing and then replacement of another implant should not be ruled out.28 Additionally. while others attribute dental implant failure to biomechanical factors. the ailing implant may have exhibited early bone loss along with soft tissue pocketing. Restorations placed on endosseous implants may cause traumatic occlusion. a patient unmotivated to control plaque around natural teeth would not be a good candidate for dental implants. while mandibular failure rates were between 4% and 5%.22 demonstrated an absolute success rate of 97.

29-32 Microflora associated with failing dental implants are identical to those found in chronic adult periodontitis.32 Peri-implantitis occurs when there is progressive peri-implant bone loss in conjunction with a soft tissue inflammatory lesion.2%). and mechanical debridement.30-33 Therefore. Their belief is low concentrations of chlorhexidine (0.16. Chlorhexidine is most often prescribed because of its antimicrobial effect and substantivity at the affected site.31. However. Failing implants have a poorer prognosis. can be defined as failing (Figure 5). occlusal therapy. other signs and symptom markers have been used to classify the ailing and failing implant. Non-Surgical Therapy The most conservative approach to treatment involves non-surgical therapy. 2. purulence.31 In contrast. and indications the bone loss patterns are progressing despite previous therapy.32 Historically.34 This microflora triggers inflammation and bone loss and is termed peri-implantitis. or other parafunctional habits are evident. The overall goal of therapy is to establish a functional restoration and acceptable esthetics. 2003 . The clinician should start conservatively and progress to more aggressive therapy. no scientific data has validated the effectiveness of chlorhexidine when used in this manner.5 mm in conjunction with a gingival recession of 1 mm and some re-growth of bone seen radiographically. Treatment resulted in a mean reduction of probing pocket depth of 2. combined with cervical fluid dilution and the apparent protective function of blood serum.30. attachment levels. an implant that is progressively losing its bone anchorage.9. but is still clinically stable. some clinicians have found this therapy to be ineffective. Tissue tone. subgingival irrigation of peri-implant pockets with 0. Occlusal interferences may contribute to ailing and failing implants. may result in the ineffectiveness of chlorhexidine.29-31 4 The Journal of Contemporary Dental Practice.38. Volume 4. and microbiological characterization of subgingival flora have all been utilized in implant classification. amoxicillin. gingival index. tissue collagenase activity. suppuration. pocket depth. mobility.11 Other pharmacological therapies include local application of tetracycline fibers and systemic antibiotics.29–31 Therefore.the 3. a failing implant may be saved. cervical fluid flow. This may be completed at home following careful instructions from the clinician or dental hygienist. if properly recognized and treated.39 Occlusal adjustment is necessary when premature contacts or interferences are present. there is currently no scientific evidence to support its use.10 Mombelli and Lang37 treated nine peri-implantitis sites non-surgically through local removal of plaque deposits.34-36 Treatment Options Treatment options for ailing and failing implants are varied. polishing accessible surfaces with pumice.32 Bacteria associated with failing implants have been found to be sensitive to the following antibiotics: penicillin G. Nightguard therapy may be indicated as well. radiographic evaluation. No. May 15. However.29. combination of amoxicillin and metronidazole. plaque index. bleeding on probing.12% to 0.17. bleeding upon probing.32 This treatment modality includes three subcategories: pharmacological therapy.to 4. any therapy provided should arrest further loss of bone support and re-establish a healthy peri-implant mucosal seal. A lamina dura indicating a state of chronicity also may be present at the borders of the osseous defect. The implant prosthesis also must be examined when grinding. The clinician must correct these occlusal errors to prevent overloading of the implant.15-17. oxygen tension levels. Although occlusal therapy seems logical. bruxing.month maintenance checks. and systemic antimicrobial therapy for 10 consecutive days. Pharmacological therapy for patients presenting with an ailing implant involves subgingival irrigation for 10 days to 3 weeks (2 to 3 times per 24 hour time period). and amoxicillinclavulanate.5% chlorhexidine. the failing implant may show evidence of pocketing. In fact.

33.. stannous fluoride. 2. Chemotherapeutic agents such as chlorhexidine gluconate. which theoretically would not only kill the periodontopathic bacteria but also would remove endotoxins from a root implant surface. hydrogen peroxide. an air-powdered abrasive system. cytotoxic. Volume 4. chlorhexidine. stannous fluoride.41 Surgical Therapy The clinician may use a surgical approach when non-surgical therapies are not indicated or are unsuccessful. These surface changes result from the infectious aspects of disease and inflammation. The clinician must remove endotoxins from the surface of the failing implant.A third non-surgical therapy recommended for treating the ailing or failing implant is mechanical debridement.36 The HA coating may be pitted.42 As long as endotoxins are present.34 An endotoxin is a heat stable. He used strips infected with endotoxins isolated from purified outer membranes of E. hydrogen peroxide. The rationale for their use is the subgingival flora associated with dental implants have been shown to be very similar to those associated with natural teeth. and tetracycline are antimicrobials and/or antibiotics. The first step in surgical therapy is exposing and treating the bacterially contaminated implant surface (Figure 6).40. This is especially true of hydroxyapatite (HA) coated surfaces.11. May 15. and polishing with rubber cup and pumice.33 Local debridement of tissues surrounding an implant using either plastic hand instruments or ultrasonic instruments with a plastic tip has been suggested. or a modified plastic Cavitron® (Dentsply York.43 The literature suggests using chemical agents to detoxify the surface of the failing implant. and polymyxin B treated groups were not effective in removing endotoxins when compared to the distilled water burnished group (control). cracked. The rubber cup with pumice actually provided the smoothest polished abutment. 2003 . there can be no biological repair.32. as the implant exhibits the subsequent loss of connective tissue attachment and establishes an osseous defect. This resorption process is similar to the effects of periodontal disease. The strips were treated with citric acid. tetracycline.41 In a comparative in vivo study. As the pH in the area becomes lower during inflammation.” the assumption is implant surfaces exposed to periodontopathogens have become contaminated with endotoxins that may interfere with the repair process. Zablotsky et al. How5 The Journal of Contemporary Dental Practice. pyrogenic and has been implicated in the causation of periodontal disease. Plastic instruments are necessary to debride plaque from titanium dental implants without damaging the soft titanium surface.32. PA 1-800-989-8826) tip or a control. None of these methods appeared to roughen the surface. the HA surface begins to decalcify and/or resorb. coli labeled with radioactive C14. Some of these agents appear to be more effective than others. No. and brownish in color and may show areas of resorption down to the base metallic substrate (Figure 7).11 studied the ability of various chemotherapeutics to detoxify infected HA-coated implant surfaces. Although it is important to note that regular toothbrush bristles can roughen the dental implant. polymyxin B. mechanical instrumentation to remove bacterial deposits also may damage the implant surface when performed with metal instruments harder than titanium. It is pro-inflammatory. lipopolysaccharide complex found in the cell wall of many Gram-negative microorganisms. In an implant subjected to “infectious failure. the surface texture of titanium implant abutments were evaluated after exposure to plastic scalers. The tetracycline.30-32.

Use of a plastic Cavitron® tip also seemed to stimulate cell attachment. the citric acid-tested group and the strips treated with the plastic Cavitron® tip were superior to the other treatment groups in endotoxin removal. and alloplastic grafts. the implant surface should be detoxified with a substance such as tetracycline paste (TCN). These findings agree with other studies that concluded detoxification of the infected HAcoated implant surface using citric acid or scaling the surface with plastic-tipped instruments may be beneficial in the surgical repair of the ailing implant. They reported implant surface treatment with tetracycline or citric acid resulted in greater cellular attachment and growth as compared with untreated groups.e. (i. 250 mg of TCN is mixed with saline in a dappen dish and applied to the metallic implant surface using a cotton pledget or camel’s hair brush. and 10). Bone-grafting materials fall into three main categories: autografts.45 Following debridement of the surgical area and removal of the infected and contaminated hydroxyapatite. May 15. TCN is intentionally left on the implant surface and the defect is then grafted with regenerative materials. Recently developed xenografts are also gaining increased attention. Volume 4. 2. or affecting cell attachment and growth to any degree). It may be composed of cortical.44 Once the implant is decontaminated. while Polymyxin B.46 Xenografts are grafts from other species. 6 The Journal of Contemporary Dental Practice. although investigation of the production steps of bovine bone have determined this material does not present a risk to transmission. stannous fluoride. the next step is to regenerate or obliterate the osseous defect with a grafting material (Figure 8.46 It is believed bovine bone and especially biologic membranes made with bovine dura mater could possibly be contaminated with bovine spongiform encephalopathy (“mad cow disease”).ever.48 Harvested bone from an edentulous area and placed around an implant site is one example of an autograft. cancellous. TCN should be left on the surface to provide additional antimicrobial benefits as well as to stimulate connective tissue healing as reported by Wittrig.44. and chlorhexidine treatment allowed for cell coverage and morphology similar to untreated controls. inhibiting.44 also investigated cellular attachment and growth of fibroblasts on HA-coated treated strips.. No. Typically. allografts.45 Wittrig et al. One type of xenograft is bovine bone. neither stimulating.44. hydrogen peroxide.47 An autograft is tissue transferred from one position into a new position in the body of the same individual. or combined cortical-cancellous bone containing within its matrix some post-osteogenic proteins capable of actual bone induction. 2003 . 9.

Shirley. These may offer some bone-inductive capacity comparable to autografts. They are classified as osteoconductive or osteophilic. sodium. such as demineralized. No. Inc. Some examples include: Bio-Gide® (Osteohealth Co. 2003 .32 Full-thickness flap management is utilized to access the surgical area. Alloplasts provide a physical.L. freeze-dried dura mater. 1-800-874-2334). decalcified bone alone. which provides an environment for bone formation by means of a scaffolding or matrix configuration.30 7 In conjunction with the various grafts discussed for bone regeneration around failing implants.54 Alloplastic grafts are synthetic graft materials that can be used as biocompatible “fillers” in helping to maintain bone and soft tissue height. moderate (<3mm) bone defects. Bone resection is an alternative implant surgical therapy.32. freeze-dried bone (DFDBA). HTR. 1-949-453-3200). CA.12. Osseous resective therapy is used to correct horizontal bone loss. Irvine. 2. biocompatible “fill.43 Non-resorbable membranes are less commonly used because of the requirement for an additional surgery to recover the intact membrane. Palm Beach Gardens. support the mucoperiosteal flap. and to reduce overall probing depth. if the implant surface cannot be cleaned and detoxified (due to vents. The Journal of Contemporary Dental Practice. Resorbable membranes are most commonly used today. a synthetically-derived material composed of microporous beads made up of polymethylmethacrylate (PMMA) and polyhydroxyl/ethylmethacrylate (PHEMA) coated with resorbable calcium hydroxide.. recommended the surgical area be isolated from the oral cavity with full-flap coverage of the membrane barrier. holes in the implant fixture. and potassium (Bioactive Glass) and Interpore 200® which is a a porous hydroxyapatite graft material (Interpore Cross.51-53 Allograft material is used to treat most surgical periodontal defects and to repair failing implants after detoxification because of the relative limited availability of autograft material. one and two-wall defects with low regenerative potential. or tortuous osseous defects not accessible to instrumentation). AZ 1-800-528-8763) pioneered both resorbable and non-resorbable membranes. CT 1-800-432-4487). Gore & Associates (Flagstaff. it is possible to graft with an allograft material such as DFDBA to achieve biologic healing. May 15. but of non-identical genetic composition.43 W. and help prevent further epithelial invagination.Allografts. If the surface is clean and detoxified. Inc. NY. and crosslinked bovine collagen.55.57 Examples of other alloplasts include: Biogran® (3i. He suggested microbial leakage at the abutment-implant junction might influence the outcome of GBR and.32 The clinician selects the appropriate surgical technique based on the type of osseous defect surrounding the failing implant. or Bioactive Glass. Danesh-Meyer9 reported partial bone fill around failing implants using guided bone regeneration (GBR) alone or in combination with autogenous bone grafts or various types of allografts and alloplasts. Bio-Gide® is a type I and III porcine derived collagen. therefore.43 However. are tissue grafts from members of the same species.56 One such alloplast is Bioplant HTR® (Bioplant. silicon. FL 1-800342-5454). clinicians also may use membranes to keep these grafts in the desired location. Bone Morphogenic Protein (BMP) is believed to become available during decalcification of the lyophilized bone.50 It is hypothesized this bone matrix contains a protein substrate that induces bone formation. or mixed with an antibiotic such as TCN may be used in therapeutic procedures.” minimize probing depth. South Norwalk. Other resorbable membranes include: vicryl mesh. it is advisable to graft with an alloplast material such as HA (particulate form).49 Lyophilized (freeze-dried). with all exposed areas of the implant visualized and instrumented. Volume 4. The decision to utilize an alloplast or an allograft depends on the effectiveness of the detoxification of the implant surface. which is a granular material consisting of calcium. demineralized freeze-dried lamellar cortical bone strips.

Implantoplasty is performed prior to beginning osseous resective therapy and must include copious irrigation to minimize excessive heat. probing around the implant is neces- sary only when pathology is suspected. Maintenance of an implant site is facilitated when implant surfaces coronal to the alveolar crest are smooth and clean. It is advised to remove the implant superstructure (if retrievable) and abutment every 18-24 months for cleaning in an ultrasonic solution.40. educating the implant patient to maintain meticulous oral hygiene and evaluating the implant both clinically and radiographically at frequent recall visits. However. the best steps to avoid encountering ailing or failing implants involve proper case selection. More research is necessary in this area to validate the current therapies used in managing ailing and failing implants.41 Dental hygienists should scale the area supragingivally and only very slightly subgingivally. Volume 4. Clinicians must keep in mind periodontal pathogens can cross-infect in the oral cavity. Probing should be minimal and accomplished using a plastic-tip probe. scalers must be strong enough to engage calculus without bending or breaking the tip. excellent surgical technique. No. Scalers must have plastic tips and be soft enough to avoid roughening or scratching the implant surface. Ailing and failing implants are amenable to therapy. unhealthy implants are uncommon because of the high success rate of implant therapy in the 21st century. 2003 . May 15. 2. Several techniques for identifying and managing ailing and failing implants have been presented in this review.58 It is imperative the implant abutment surface be kept smooth to facilitate plaque control procedures by the patient. Undoubtedly. 8 The Journal of Contemporary Dental Practice.Maintenance Regular professional maintenance is necessary to detect and manage implants that are ailing. roughened topography.58 Radiographs should be exposed every 12 months to detect any bone level changes.32.15 reported the transmission of periodontopathic organisms from active periodontal sites to implant sites in the same mouth is a likely event. it is essential for the clinician to recognize unhealthy implants and to determine whether they are ailing. placing an adequate restoration on the implant.58 The implant patient should return to the dental office every three months. failing. The clinician should implement a clinical protocol that includes the elimination of periodontal disease in prospective implant patients. Implants diagnosed as failed should be removed. or have failed. continuous titanium surface on implants having exposed threads. or failed prior to beginning any salvage efforts. In addition. or coated with HA (Figure 11). Gouvoussis et al. The clinician and hygienist must reinforce plaque control with the implant patient. failing. During this recall appointment. Implantoplasty involves using high-speed finishing and polishing burs to produce a smooth. Summary Fortunately.

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Fowler. May 15. GA and Dr. Thomas Anderson of the Canadian Forces Dental Services. 2. Columbus. 2003 . Boretsky.“The authors thank the following individuals for their photo contributions: Dr. No. Bruce A. Volume 4. Puyallup. WA. Edward B.” 12 The Journal of Contemporary Dental Practice. Dr.